tions to the problems posed by aflatoxins in tropical developing countries.
RALPH GEORGE HENDRICKSE, MD
(CAPE TowN), FRCP (EDIN & LOND),
FMC PAED(NIGERIA)
Department of Tropical Paediatrics &
International Child Health University of Liverpool
School of Tropical Medicine
Liverpool L3 5QA, United Kingdom
REFERENCES
1. Puffer RR, Serrano CV. Patterns of Mortality in Childhood. Washington, DC: PAHO Scientific Publication; 1973;262 2. Williams CD. A nutritional disease of children associated
with a maize diet. Arch Dis Child. 1933;8:423
3. Williams CO. Kwashiorkor, a nutritional disease of children associated with maize diet. Lancet. 1935;2:1151
4. Gopalan C. Kwashiorkor and marasmus: evolution and dis-tinguishing features. In: McCance RA, Widdowson R, eds. Calorie Deficiencies and Protein Deficiencies. Edinburgh: Churchill Livingstone; 1968:49-58
5. Brock JF, Autret N. Kwashiorkor in Africa. WHO Monogr Ser. 1952;8
6. Trowell HC, Davies JN, Dean RFA. Kwashiorkor. London: Edward Arnold; 1954
7. Alleyne GAO, Hay RW, Picou DI, Stanfield JP, Whitehead RG. Protein Energy Malnutrition. London: Edward Arnold; 1977
8. Goldblatt LA. Aflatoxin. New York: Academic Press; 1969 9. Busby WF, Wogan GN. Aflatoxins. In: Shank RC, ed.
My-cotoxins and N-Nitroso Compounds: Environmental Risks. Boca Raton: CRC Press; 1981;2:3-27
10. Richard JL, Thurston JR, Pier AC. Effects of mycotoxins on immunity. In: Rosenberg P, ed. Toxins: Animals, Plant and Microbiology. Oxford: Pergamon Press; 1978:801-817 1 1. World Health Organization. Environmental Health Criteria
2. Geneva: WHO; 1979
12. Weilcome Trust Working Party. Lancet. 1970;2:302 13. Hendrickse RG, Coulter JBS, Lamplugh SM, et al.
Aflatox-ins and kwashiorkor: a study in Sudanese children. Br Med
J.1982;285:843-846
14. de Vries HR, Lamplugh SM, Hendrickse RG. Aflatoxins and kwashiorkor in Kenya: a hospital based study in arural
area of Kenya. Ann Trop Paediatr. 1987;7:249-257
15. Hendrickse RG, Lamplugh SM. Aflatoxins and child health in the tropics with special reference to kwashiorkor and Reye’s syndrome. Final Report to the Commission of the European Communities Director General for Science & De-velopment; 1987
16. Lamplugh SM, Hendrickse RG. Aflatoxins in the livers of children with kwashiorkor. Ann Trop Paediatr. 1982;2:101-104
17. Apeagyei F, Lamplugh SM, Hendrickse RG, Affram K, Lucas S. Aflatoxins in the livers of children with
kwashior-kor in Ghana. Trop Geogr Med. 1985;273:6
18. de Vries HR, Lamplugh SM. Aflatoxins and liver biopsies from Kenya. Trop Geogr Med. 1987:26-30
19. Coulter JBS, Hendrickse RG, Lamplugh SM, et a!. Aflatox-ins and kwashiorkor: clinical studies in Sudanese children. Trans R Soc Trop Med Hyg. 1986;80:945-951
20. Lamplugh SM, Apeagyei F, Mwanmut D, Hendrickse RG. Aflatoxins in breast milk, neonatal cord blood and serum of pregnant women. Br Med J. 1988;296:968
21. Maxwell SM, Apeagyei F, de Vries HR, Mwanmut DD, Hendrickse RG. Aflatoxins in breast milk, neonatal cord blood and sera of pregnant women. Toxicol Toxin Rev. 1989;8:19-29
22. Hendrickse RG, Lamplugh SM, Maegraith BG. Influence of aflatoxins on nutrition and malaria in mice. Trans R Soc Trop Med Hyg. 1986;80:846-847
23. Hendrickse RG, Hasan H, Olumide LO, Akinkumi A. Ma-lana in early childhood. An investigation of 500 seriously ill children in whom a “clinical” diagnosis of malaria was made on admission to the Children’s Emergency Room at Univer-sity Children’s Hospital, Ibadan. Ann Trop Med Hyg. 1971;65:1-20
24. Eddington GM, Gilles HB. Disorders of nutrition. In: Ed-dington GM, Gilles HB, eds. Pathology in the Tropics. Lon-don: Edward Arnold; 1976:668-688
25. de Vries HR, Maxwell SM, Hendrickse RG. Aflatoxin ex-cretion in children with kwashiorkor or marasmic kwashior-kor: a clinical investigation. Mycopathologia. 1990;110:1-9 26. Golden BE, Golden MHN. Plasma zinc and the clinical
features of malnutrition. Am J Clin Nutr. 1979;32:2490-2494
27. Golden MHN, Golden BE, Harland PSEG, Jackson AA. Zinc and immunocompetence in protein-energy
malnutri-tion. Lancet. 1978;1:1226-1227
28. Golden MHN, Jackson AA, Golden BE. Effect of zinc of thymus of recently nourished children. Lancet.
1977;2:1057-1059
29. Golden MHN. Consequences of protein deficiency in man and its relationship to features of kwashiorkors. In: Blaxter K, Waterlow JC, eds. Adaptation in Man. Rank Prize Funds Symposium. London: Libbey; 1985:169-187
Remembering
As We Look
Ahead:
The
Three
E’s and
Firearm
Injuries
There was a little man, and he had a little gun, And his bullets were made of lead, lead, lead; He went to the brook, and he saw a little duck,
And he shot it through the head, head, head.
-Mother Goose
Four decades ago, Harry Dietrich,’ a member of
the American Academy of Pediatrics’ newly estab-lished Accident Prevention Committee, described a
developmentally based approach to the prevention
of childhood injury. Dietrich stressed the great need
for protection (“passive immunization”) for the
young child and for safety education (“active
im-munization”) as the child matures. It was also in
the early 1950s that George Wheatley, the first chairman of the Accident Prevention Committee,
popularized the “three E’s”2-education,
enforce-ment, and engineering-as a framework for
devel-oping and categorizing strategies to prevent
inju-ries. Today this conceptual framework remains
sound. To prevent injuries we can educate (or per-suade), we can promote legislation or regulations, and we can introduce engineering innovations and modifications into the child’s environment.
The second E (enforcement) is more likely to be
effective in preventing injuries than the first
(edu-cation), and the third E (engineering) is most likely of all to be effective.3Sm) This ranking reflects the consistent observation that habits of human behavior are difficult to change. We know relatively little of the behaviors leading to childhood injury.6 We know even less about changing those behaviors.
ENGINEERING
An example of the application of environmental
engineering to prevent injury is the use of fuses or
circuit breakers in home electrical systems. Think
how difficult it would be to teach electrical safety at home without this simple technology. People would have to learn how to calculate amperage
drawn by various electrical appliances and lights to
avoid overloading circuits and causing a house fire. Another electrical example of environmental
engi-neering (or product design) with built-in safety is
the telephone. While we must take care not to get an electric hair dryer wet, and not to stick a fork in the toaster, we do not have similar concerns about the telephone. Because telephones have the
built-in safety of low electrical current, neither use nor
misuse can result in electrocution.
Although we may take it for granted, the auto-mobile also has a variety of engineering innovations
that “automatically” offer a measure of safety.7 A
padded dash and steering column provide a measure
of protection for occupants of the front seat
whether or not they remember or choose to fasten their seat belts. All currently manufactured
passen-ger autos sold in the United States also provide
occupants of the front seat with passive restraint
systems, either in the form of “automatic belts” or
air bags. The air bag is preferable to automatic belt
because the former is more dif ficult to circumvent.
ENFORCEMENT
Legal regulation (“enforcement”) often plays a
major role in injury prevention in situations where
an engineering solution is unavailable or
impracti-cal. The swimming pool, the back seat of the car,
and home fire prevention are pertinent examples.
A drown-proof backyard swimming pool has yet to
be engineered. However, we can require that
home-owners surround their pools with appropriate
fences and gates to provide protection for both the children living in the home and for the neighbors’
children.8 The success of legislation requiring the
use of child automotive safety seats has been well documented.9” Regulations are necessary to insure that existing technology be utilized to save lives and prevent injury from house fires. Smoke
detec-tors provide good “passive” protection only if
prop-erly installed and periodically tested.’2 Therefore,
residential building codes now generally require
that smoke detectors be installed in new
construc-tion. Smoke detectors should also be required in
existing homes. Strong arguments can be made for residential sprinkler systems as well.’2”3 Likewise, the practical technology for manufacture of “fire safe” cigarettes is available, but for this technology
to save lives, we will need cigarette fire safety
standards (legislation or regulations.)’2”4
EDUCATION
When product design and legislation are not
suf-ficient, we must depend on our less reliable ability
to influence behavior through education and
per-suasion. Bicycle safety is an example: persuading
riders to wear helmets.’5”6 Prevention of choking
on food’7 is another example. That is why pediatri-cians devote time on or around the 6-month-old
routine visit discussing with parents which finger
foods are appropriate and which are not. (Sliced hot dogs, nuts, peanuts, whole grapes, and chunks of hard vegetables are to be avoided. Softer foods
that either dissolve or crumble are preferred.’8) As
evidence of our limitations in this area of
counsel-ing, time should also be devoted at the 6-month
visit to a review of first aid for a choking infant,
particularly the use of “back blows” to create an
“artificial cough” and the importance of doing
noth-ing if the infant retains an effective cough.’8”9
Pedestrian safety is an area that is highly
de-pendent on behavior modification. Theoretically, we could design an urban environment that “auto-matically” protected child pedestrians by assuring that their paths never cross those of motor vehicles. But because we have inherited an urban landscape that is booby-trapped with man-machine intersec-tions, and because it would be prohibitively
expen-sive to retrofit completely that landscape with a
network of safe walkways, we are left with teaching children to stop at the curb, to look “left-right-left,” and then to cross when the way is clear. We are at an early stage in the study of behavioral interven-tions in the area of pedestrian safety; such study should be high on the research agenda.20’2’
BLENDING STRATEGIES
The astute reader will recognize that the
place-ment of strategies into behavioral, enforcement,
A particular strategy frequently has elements of
more than one of the three E’s. For example,
leg-islation can help assure that technology is used. The Flammable Fabrics Act22 authorized regula-tions to assure that flame-retardant fabrics are used
in the manufacture of children’s sleepwear. The
Poison Prevention Packaging Act23 assures that
child-resistant packaging is utilized for most
pre-scription drugs and many poisonous household
products. Regulations requiring smoke detector in-stallation also assure the use of technology. Car seat legislation would be useless without the avail-ability of crash-tested restraint systems.
BEHAVIOR
Our limitations in behavior modification not-withstanding, we should recognize that, fundamen-tally, all safety is behavior-dependent. It is only a
matter of whose behavior must be influenced.
Influ-ending the behavior of a population of at-risk
mdi-viduals and families is a high challenge. It is also a
considerable challenge to influence the behavior of legislators to pass car seat legislation or the behav-ior of regulators to require the use of flame-retar-dant fabrics in children’s sleepwear. And with
re-gard to engineering, behaviors and decisions of
urban planners, architects, product designers, and
corporate decision-makers likewise must be
influ-enced so that our children’s man-made
environ-ment will have a generous measure ofbuilt-in safety and so that further technical innovation can flour-ish.24
GUNS
It is within the framework of the “three E’s” that
the paper by Christoffel25 in this issue of Pediatrics
ought be considered. Guns are consumer products.26
Their manufacture, distribution, and sale are
sub-ject to the same marketplace forces as those that
apply to hair dryers, toasters, toys, automobiles,
and washing machines. Guns can be designed with
more or less built-in safety, depending, no doubt,
on the incentives and disincentives brought to bear
upon designers, manufacturers, and distributors by
legislation, regulations, and educated consumers.
Yet, because guns are designed to be weapons, built-in safety has its limits. Therefore we cannot ignore
strategies aimed at modifying the purchase, use,
and storage of guns, namely education (persuasion) and enforcement (legislation and regulation).
Injuries are a public health problem as well as a
personal health problem.3’27 Keeping this in mind is essential for the prevention of firearm injuries.
From a public health standpoint, it is important
that we demystify the firearm by relieving it of its
political and emotional baggage. In so doing, we
come to see gun injuries as but one example of
pediatric “product-related” injuries, of which we
have many other less destructive examples.
Pediatricians are witnessing too many young
peo-ple falling victim to firearms.28 Our society can no
longer afford to consider firearms as sacrosanct.
We have been told that the unencumbered distri-bution ofguns in the marketplace is a constitutional
right (it is not29), and that the design of guns and
ammunition are fixed for utilitarian reasons and
not amenable to safety modification (also not
true30). The truth is that gun manufacturers have
never had much incentive to redesign their weapons
to make them less convenient to shoot. It is unclear
why gun manufacturers should be held to a lower
standard of accountability than the manufacturers
oftoasters or telephones. Why is it that a high chair
that can pinch a finger is withdrawn promptly from
the market, whereas the unencumbered commerce
in guns that 6-year-olds can discharge
unintention-ally, or that 10-year-olds can discharge
purpose-fully, remains unquestioned?
GUN INJURIES IN PERSPECTIVE
In October, 1990, a round table was held at the American Academy of Pediatrics Annual Meeting
in Boston to commemorate the 40th anniversary of
the Accident Prevention Committee (now renamed
the Committee on Injury and Poison Prevention).
At that meeting, past chairmen of the Committee
reported upon the progress we have made in the
prevention of childhood injuries during the past 40
years. We were reminded that one of the first issues
taken up by the newly established committee in
1950 was the prevention of poisoning. Drs George
Wheatley, Edward Press, and others who sat on
that original committee articulated the problem and
promoted strategies to prevent poisoning in an
ex-emplary manner. (The members of the original
Accident Prevention Committee were: George M.
Wheatley (Chair), Jay M. Arena, Esther B. Clark,
Harry F. Deitrich, Albert D. Kaiser, Richard H.
Kotte, Donald D. Posson, and Edward Press [who
was subsequently appointed chair of the Poison
Prevention Subcommittee].) In a similar fashion,
the early Accident Prevention Committee set out to identify issues and promote strategies to prevent
clothing ignition and to prevent injuries from
ju-venile furniture, baby carriages, strollers, and
haz-ardous toys. This early work continues to serve as
a model for pediatricians involved in injury
preven-tion. Early injury strategies, like those of today,
involved a blend of education, regulation, and
in-novative technology. Edward Press received the
his contribution in the establishment of poison-control information centers in this country.3”32 The development of child-resistant packaging, legislation23 and regulations33 to assure its use, and declines in accidental poisonings34 followed in sub-sequent years.
At the 40th Anniversary round table in Boston, George Wheatley said:
.. .our concern is with the nonbiologic vectors in the child’s environment which threaten life and limb. Dealing with these vectors requires pediatricians to leave their familiar medical world to work with those who wittingly or unwittingly create the hazards that injure children.
Environmental threats constantly change. To remind us
of this, consider that at the birth of the Accident
Corn-mittee in 1950, we were occupied with eliminating the
risk of lead poisoning due to the ingestion of paint chips. Today, our concern is with the high risk to children of “lead poisoning” from stray bullets.’5
This “lead poisoning”-this play on words
acci-dentally apt in reference to Dr Christoffel’s arti-cle-should not distract us from the highly practical analogy between injuries caused by guns and inju-ries caused by any of the other nonbiologic vectors. As the Committee enters its fifth decade, we have witnessed remarkable declines in injury rates from
a variety ofcauses.36 To replicate such declines with
regard to gunfire injuries will require that we dili-gently apply a time-proven formula, remembering
that none of the three E’s is off limits.
ACKNOWLEDGMENT
George Wheatley’s paper, “Accident and Poison
Pre-vention: A Look Back,” delivered at the Boston round
table, inspired this commentary. I further benefited from
George Wheatley’s and Edward Press’s recollections of
the early work of the Accident Committee. Rosemary Siwkowski of the Academy staff discovered for me the minutes and reports of the first meetings of the Accident Prevention Committee.
REFERENCES
MARK D. WIDOME, MD, MPH
Department of Pediatrics
The Pennsylvania State University College of Medicine
Hershey
1. Dietrich HF. Accidents, childhood’s greatest physical threat,
are preventable. JAMA. 1950;144:1175-1179
2. Wheatley GM. Committee on Accident Prevention Annual Report to the Executive Board. Chicago: American Academy of Pediatrics; August 4, 1954
3. Committee on Trauma Research, National Research Coun-cil and the Institute of Medicine. Injury in America A Continuing Public Health Problem. Washington, DC: Na-tional Academy Press; 1985
4. Greensher J. Recent advances in injury prevention. Pediatr Rev. 1988;10;171-177
5. Robertson L. Injuries: Causes, Control Strategies, and Public
Policy. Lexington, MA: Lexington Books; 1983
6. Scheidt PC. Behavioral research toward prevention of child-hood injury: report of a workshop sponsored by the National Institute of Child Health and Human Development, Sept
3-5, 1986. AJDC. 1988;142:612-617
7. AMA Council on Scientific Affairs. Automobile-related in-juries: components, trends, prevention. JAMA. 1983;
249:3216-3222
8. Wintemute GJ. Childhood drowning and near-drowning in the United States. AJDC. 1990;144:663-669
9. Decker MD, Dewey MJ, Hutcheson RH, Schaffner W. The use and efficacy of child restraint devices. JAMA.
1984;252:2571-2575
10. Agran PF, Dunkle DE, Winn DG. Effects of legislation on motor vehicle injuries to children. AJDC. l987;141:959-964 11. Margolis LH, Wagenaar AC, Liu W. The effects of a
man-datory child restraint law on injuries requiring
hospitaliza-tion.AJDC. l988;142:1099-1103
12. McLoughlin E, McGuire A. The causes, cost, and prevention of childhood burn injury. AJDC. 1990;144:677-683
13. AMA Council on Scientific Affairs. Preventing death and injury from fires with automatic sprinklers and smoke de-tectors. JAMA. l987;257:1618-1620
14. Bodkin JR. The fire-safe cigarette. JAMA. 1988;260:226-229
15. Bergman AB, Rivara FP, Richards DD, Rogers LW. The Seattle children’s bicycle helmet campaign. AJDC. 1990;144:727-731
16. Committee on Accident and Poison Prevention, American Academy of Pediatrics. Bicycle helmets. Pediatrics.
1990;85:229-230
17. Harris CS, Baker SP, Smith GA, Harris FM. Childhood asphyxiation by food: a national analysis and overview.
JAMA. 1984:251:2231-2235
18. American Academy of Pediatrics. Choking Prevention and First Aid for Infants and Children (pamphlet). Elk Grove Village, IL: American Academy of Pediatrics; 1988 19. Committee on Accident and Poison Prevention, American
Academy of Pediatrics. First aid for the choking child, 1988.
Pediatrics. 1988;8l:740-742
20. Tanz RR, Christoffel KK. Pedestrian injury: the next motor vehicle injury challenge. AJDC. 1985;139:1187-1190
21. Rivara FP. Child pedestrian injuries in the United States. Current status of the problem, potential interventions and future research needs. AJDC. l990;144:692-696
22. The Flammable Fabrics Act, 15 USC §1261 et seq 23. Poison Prevention Packaging Act of 1970, 15 USC
§1471-1475
24. Wilson MH, Baker SP, Teret SP, Shock 5, Garbarino J. Saving Children: A Guide to Injury Prevention. New York: Oxford University Press; 1991. In press
25. Christoffel KK. Toward reducing pediatric firearm injuries: charting a legislative and regulatory course. Pediatrics. 1991;88:294-305
26. Goldsmith MF. Epidemiologists aim at new target: health risk of handgun proliferation. JAMA. 1989;261:675-676 27. Widome MD. Economy, convenience, and safety: can we
have it all? Pediatrics. 1990;86:785-787
28. O’Connor KG, LeBailly SA, Fleming GV. Periodic Member-ship Survey 3. Elk Grove Village, IL: Department of Re-search, American Academy of Pediatrics; 1988
29. Christoffel T. Current federal, state, and local regulations and legislation. In: Report of a Forum on Firearms and Children, August 30-September 1, 1989 (sponsored by the American Academy of Pediatrics and the Henry J. Kaiser Family Foundation). Elk Grove Village, IL: American Acad-emy of Pediatrics; 1989
Received for publication Nov 5, 1990; accepted Feb 7, 1991. PEDIATRICS (ISSN 0031 4005). Copyright © 1991 by the American Academy of Pediatrics.
31. Wheatley GM. Prevention of accidents in children. Adv Pediatr. 1956;8:191-215
32. Scherz RG. The history of poison control centers in the United States. Clin Toxicol. 1978;12:291-296
33. Poison Prevention Packaging Act of 1970 Regulations.
1988;16 CFR Part 1700
34. Walton WW. An evaluation of the poison prevention pack-aging act. Pediatrics. 1982;69:363-370
35. Wheatley GM. Accident and poison prevention, a look back. Presented at 40 Years of Injury Prevention, An Injury Prevention Round Table at the Annual Meeting, American Academy of Pediatrics; October 9, 1990; Boston, MA 36. Metropolitan Life Insurance Company. Mortality from
lead-ing types of accidents, 1976-77 and 1986-87. Stat Bull Metrop Life Irzsur Co. l990;71(Jan-Mar):22-27
The Academic
Generalist:
Still
an
Endangered
Species?
In his recent article,’ Dr Haggerty touches on one
of the most important issues facing departments of
pediatrics, namely, the roles of the academic
gen-eralist and sections/divisions of general pediatrics. Our comments are not intended to be a critique of
the article but rather to expand the discussion with
the hope that solutions to some of the problems
will be found rapidly.
Excellent teaching is clearly an academic
func-tion. Therefore, we would hope that, in the area of
education, the academic generalist has never been
an endangered species and no revival is necessary!
As Dr Haggerty appropriately notes,
sections/divi-sions of general pediatrics assume the major
teach-ing obligation in many departments of pediatrics.
A large percentage of a 3-year residency is (or
should be) spent in the clinics. A major portion of
the required student clerkships in pediatrics com-prises (or should comprise) experience in various outpatient arenas.2’3 However, the one-on-one
teaching in the clinics is an “expensive” type of
teaching-”expensive” in time, energy, resources,
and financial costs-as compared with ward
teach-ing by an attending physician and his or her
entou-rage. Which is “better” is dependent on the teacher.
Because of these extensive teaching obligations, it
is not surprising that sections or divisions of general
pediatrics have become the largest academic units
in many departments of pediatrics.’3 As Dr
Hag-gerty points out, these heavy teaching and
accom-panying clinical responsibilities leave little time for
other academic activities. A solution to this time
problem would be the hiring of additional academic
generalists. But who pays for these teaching
obli-gations?4 Most departments and medical schools do
not have “extra” dollars available for pure teaching
functions. Patient care revenues may not or should
not cover these costs. Salary support from grants
could be a solution but, for reasons discussed below,
may not be a major source of funds.
Other tasks have been added to the teaching and
associated service responsibilities of the academic
generalist. These are summarized by Dr Haggerty
and depicted in the figure in his article. Inpatient
attending, newborn nursery attending, community
involvement, child and sexual abuse clinics, conti-nuity clinics, etc, impose additional time con-straints. Some, or most, of these activities may
generate dollars but may not have quality teaching
and/or research components. All this often is done
in a milieu that does not reward teaching in the
same manner as research. If, in fact, colleges of
medicine and their universities recognized
excel-lence in teaching (which should include the
devel-opment and testing of new and innovative teaching
modalities) to the same extent as excellence in
research, then perhaps some of the frustrations of
faculty in sections/divisions of general pediatrics
would be minimized because professional
advance-ment would be more readily achievable. Such
red-ognition is now beginning to occur in some medical
schools.
Although no revival may be necessary for the
teaching roles of academic generalists, we are not
convinced that a revival has occurred for their
research activities as implied by Dr Haggerty. We would feel more confident about such a resurgence if additional data were available. Nearly one-third
of the trainees in the Robert Wood Johnson
Pro-gram are not in academic medicine. How many
chose not to enter academic medicine following
their fellowship? Why? How many have left
ada-demic medicine? If the majority of the one third who left did so after joining a faculty, this would
appear to be considerably higher than the
percent-age leaving academia from other pediatric
subspe-cialties. Why have so many left? What were their causes of dissatisfaction? Were they not promoted?
We also do not know what percentage of the
re-maining graduates of the program have advanced
within their academic institutions. How many have been on the classic tenure track? How many have
been on the clinical track? How many have been
promoted? Given tenure? While the quantity of
